Pioneer Care and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain potentially hazardous foods at safe temperatures during holding and distribution for residents receiving meals prepared by the facility's kitchen. The failure increased the risk of foodborne illness for all residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and communicate an effective process for submitting anonymous grievances for 2 (#s 13 and 27) of 34 sampled and supplemental residents. The failure impeded residents' ability to exercise their right to voice grievances by failing to communicate how and where anonymous grievances could be submitted.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure beds and belongings were kept a safe distance away from baseboard heaters, and the facility staff were informed of the risk the heaters posed due to fire/injury, for 7 (#s 8, 28, 39, 55, 60, 64, and 71) of 7 resident rooms sampled for heater hazards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper hand hygiene when moving between wounds during cares for 1 (#8); failed to ensure hand hygiene was performed during meal service for 2 (#14 and 54); failed to ensure linens were handled to prevent contamination between clean linens and dirty linens for 1 (#8); failed to use clean dishes during meal service for 1 (#2); and failed to clean equipment after use with resident for 1(#8) of 34 sampled and supplemental residents. These deficient practices placed residents at risk for the spread of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure showers and grooming were provided for 1 (#71) of 34 sampled and supplemental residents. This deficient practice resulted in resident #71 not being offered a shower or grooming seven times during the month of May 2026, placing resident #71 at risk of infections and compromised the resident's right to maintain personal hygiene and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR Level I was completed for 1 (#3) of 34 sampled and supplemental residents. This deficient practice resulted in resident #3 not receiving potentially needed mental health services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all physician orders were signed and dated for 1 (#29) of 34 sampled and supplemental residents. This deficient practice placed residents at risk of medication errors.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary services and supervision to prevent a resident with dementia from continuing to enter other residents' rooms after an altercation with injury. The failure increased the risk for emotional distress and physical injury for 1 (#3) of 8 sampled residents and placed other residents at elevated risk for physical or verbal altercations.

Inspectors wroteBased on interview and record review, the facility failed to identify and implement beneficial interventions to prevent further falls for a resident with dementia, limited safety awareness, and who was at risk for falls. The resident used psychotropic medications and the care plan contained only minimal fall interventions and the resident had an unwitnessed fall and had head lacerations. The resident had subsequent falls and sustained a fractured hip for 1 (#10) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical director effectively coordinated medical care for 1 (#20) of 17 sampled residents. The medical director was not responsive to the nursing staff when direction was needed regarding resident care issues. The medical director was also an attending physician for numerous residents in the facility. There was no process to ensure there were no concerns with the individuals' performance as a physician. The facility failed to have a process for how to address concerns with the medical directors' care of residents. This deficient practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have an antibiotic stewardship program, which had the potential to affect all residents who received antibiotics in the facility. The facility failed to ensure the pharmacy delivered medications and completed monthly drug regimen reviews for all residents from May 2024 through April 2025. The facility failed to ensure a current QAPI (Quality Assurance and Performance Improvement) plan was developed. The QAPI plan had not been reviewed and revised for more than two years. Goal dates on the Quality Assurance & Performance Improvement (QAPI) Plan for the facility were documented as 12/1/2022.

Inspectors wroteBased on interview and record review, the facility failed to have a designated infection preventionist for the facility. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to address the timely completion or implementation of treatment wishes, specifically related to the Provider Orders for Life-Sustaining Treatment (POLST) forms, and ensure the forms were complete so the document would not be voided, for 3 (#s 9, 16, and 20) and failed to ensure a resident's code status was consistently correct for 1 (#22) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist sufficiently addressed and documented the monthly medication regimen reviews for 1 (#10) of 17 sampled residents, and the resident received medications for anxiety and depression which fell into the classification of a psychotropics per CMS; and failed to complete the monthly medication regimen reviews with recommendations to ensure residents were provided the appropriate medications and doses to treat their diagnoses, for 4 (#s 3, 22, 24, and 35) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to use antibiotics in accordance with accepted standards, identify a residents potential colonization of a specific organism causing the resident to be on almost continuous antibiotics for several months, gave two different antibiotics at the same time for the same UTI, and the resident contracted Clostridium difficile for 1 (#35) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of residen to resident abuse, as it was not identified as abuse for 2 (#s 47 and 53); and failed to report two injuries of unknown origin for a resident, one of the injuries was a major injury, for 1 (# 10) within 24 hours of the incidents of 17 sampled residents for abuse reporting.

Inspectors wroteBased on interview and record review, the facility failed to ensure the required elements of education, physician and management notifications, and documentation of an AMA discharge, were completed for 1 (#55) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents transferring or discharging to the hospital were provided the transfer discharge notice and bedhold for 1 (#3) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours after admission to reflect the resident's care needs, for 1 (#10) of 17 sampled residents. This increased the risk of staff not providing necessary care and services due to the lack of the baseline care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and provide the needed ADL assistance for dining for 1 (#3) of 17 sampled residents. Findings Include: During an interview on 5/6/25 at 9:59 a.m., resident #3 was in her room sitting in her wheelchair, and she was clearing her throat and coughing, and stated the facility staff 'don't feed me right.' Resident #3 stated she had a hard time with a regular fork and spoon, and she had tried built up (adaptive) silverware in the past, but they had not been tried in a while. Resident #3 stated she was to get a walled (adaptive plate) plate but it did not always happen. During an observation on 5/7/25 at 12:37 p.m., resident #3 was in the assisted dining room at a table with another resident, and a staff member facing away from resident #3. Resident #3 had a large bowl with a mix of food and dinner roll on top. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor a resident's meal intake, feeding abilities, and address suspected scale errors in relation to a resident's severe weight loss, although the weight loss was desireable, for 1 (#22) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to get immediate physician orders for a resident experiencing chest pain and respiratory concerns, who was three days later sent emergently to the hospital, for 1 (#44) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective pain management and monitoring for a resident which resulted in her getting more medication than prescribed for 1 (#35) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 (#12) of 17 sampled residents.

Inspectors wroteBased on observation, and interview, the facility licensed staff failed to ensure the medication carts were secured and locked when the carts were unattended. This failure increased the risk of drug diversion, or the medication may be taken by a resident as packets of pills were hanging from a cart. This failure could affect any resident at the facility who had medications stored in the unsecured carts. During an observation on 5/6/25 at 5:00 p.m., the med cart in front of the main nursing desk was unlocked. During an observation on 5/7/25 at 8:57 a.m., the med cart in the dining room was unlocked. The nurse was away from the cart giving medications, with the cart behind a pillar, out of sight. During an observation on 5/7/25 at 8:59 a.m., there was a med cart on the 100-hallway unlocked, with the top drawer open, Pill packets were hanging out. There were no staff in the hallway. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed hand hygiene during medication pass; and failed to implement enhanced barrier precautions and signage for 2 (#s 21 and 44) of 17 sampled residents.

Inspectors wroteBased on interview and record review, it was identified the facility abuse education was not adequate to ensure administrative staff had necessary knowledge related to identification of abuse allegations, for a resident who had cognitive deficits, and management of the events for future prevention, for 2 (#s 10 and 53) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the administration of services were delivered in a manner which encouraged the residents to report concerns or complaints if they had them, without worries of retaliation for 4 (#s 1, 10, 11, and 12) of 14 sampled residents. The facility's leadership team and oversight of recent changes, and specifically the administrator's actions, resulted in concerns among the residents, and they reported it affected their mood, morale, anxiety, feelings of being kicked out of the facility, and some said they isolated to their room more. Resident #s 1, 11, and 12 reported they no longer participated in activities and had not been eating their meals in the dining room.

Inspectors wroteBased on interview and record review, the facility failed to consistently have physician ordered medications available, to ensure residents did not miss a dose of the ordered medications, for 1 (#1) of 14 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to crush medications as ordered by the physician, for 1 (#1) of 5 sampled residents with a diagnosis of difficulty swallowing. This resulted in the resident being transferred to the emergency department and hospitalized for aspiration pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a staff member adhered to proper infection control procedures while assisting a resident with drink service, for 1 (#4) of 5 sampled residents. This deficient practice had the potential to spread infectious pathogens between residents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure an ongoing systemic approach was utilized for managing a resident with a known history of elopement attempts, by failing to ensure the resident was evaluated timely and as needed throughout his stay, for future elopement prevention as the resident continued to attempt to elope; and the facility failed to ensure staff were made aware of the resident's risk for elopement and process utilized for residents who were an elopement risk, and resident #1 eloped, sustained an injury, and was hospitalized for monitoring, for 1 (#1) of 12 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the root cause of falls for the implementation of individualized interventions; and failed to ensure resident care plans were updated with interventions addressing the residents' current medical, physical, and cognitive limitations for 2 (#s 42 and 49) of 2 residents sampled for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow diet textures for 2 (#s 13 and 22) of 6 residents sampled for diet textures. This deficiency caused resident #13 to have two documented choking episodes and had the potential to cause resident #22 to have choking episodes or aspiration of food. Additionally, the facility failed to follow a low carbohydrate diet with double portions of protein for 1 (#40) of 1 resident sampled for a controlled carbohydrate diet. This deficiency resulted in an increase in resident #40's blood sugar and caused him to be concerned his healing would be delayed and his ability to discharge home from the facility would be delayed.

Inspectors wroteBased on observation and record review, the facility failed to store food in accordance with professional standards by failing to label and date food stored in the facility's freezer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was clean, well maintained, and safe for 3 (#s 23, 27 and 40) of 23 sampled residents. This deficiency had the potential to affect all residents in the facility who walk or use wheelchairs in the hallways and areas with baseboard heaters and who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to update care plans for 3 (#s 36, 42, and 49) of 23 sampled residents. Resident #36 had repeated behaviors documented and no updates or changes in interventions were made on his care plan resulting in continued behaviors. Residents #42 and #49 had repeated falls documented and no updates or changes in interventions were made on their care plans resulting in repeated falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's dignity and clean appearance by implementing measures or assistance to keep his clothing free of food debris for 1 (#42) of 23 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health services for 2 (#s 6 and 36) of 2 residents sampled for behavioral concerns. This deficiency had the potential to lead to psychological harm for resident #s 6 and 36.

Inspectors wroteBased on interview and record review, the facility failed to provide medical social services for 1 (#36) of 2 residents sampled for behavioral concerns. This deficiency had the potential to negatively impact the resident's psychological and mental wellbeing.

Inspectors wroteBased on interview and record review, the facility delayed physical therapy services for a post stroke resident for 1 (#47) of 1 resident sampled for physical therapy services. This deficient practice resulted in the resident not receiving physical therapy for 47 days after admission to the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal vaccinations for 1 (#44) of 5 residents sampled for pneumococcal vaccination or declination.

Inspectors wroteBased on interview and record review, the facility failed to offer Covid-19 vaccinations to 1 (#44) of 5 residents sampled for Covid-19 vaccination or declination.

Inspectors wroteBased on interview and record review, the facility failed to document the basis for a resident's facility-initiated immediate transfer and discharge, for 1 (#2) of 1 resident sampled for discharge concerns. This deficient practice resulted in the resident being improperly discharged from the facility, to the hospital, and then the facility would not accept the resident for readmission. This resulted in the resident being discharged to a location 4 hours away.

Inspectors wroteBased on interview and record review, the facility failed to follow and adhere to transfer and discharge notification requirements, for a facility-initiated, immediate discharge, for 1 (#2) of 1 resident sampled for improper discharge concerns.

Inspectors wroteBased on interview and record review, the facility failed to allow a resident to return and resume residence at the facility for 1 (#2) of 1 resident sampled for discharge concerns, after a facility initiated discharge to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident cash was protected from theft or misuse for 1 (#4) of 5 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a suspected misappropriation of resident money to the State Survey Agency within the required time frame for 1 (#4) of 5 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to revise a care plan to include a deep brain stimulator for the treatment of Parkinson's symptoms for 1 (#1) of 5 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to address and obtain services for 1 (#1) of 5 sampled residents with an implanted deep brain stimulator.